Revista Brasileira de Psiquiatria. 2014;36:S21–S27 ß 2014 Associac¸a˜ o Brasileira de Psiquiatria doi:10.1590/1516-4446-2013-1218 UPDATE ARTICLE Hypochondriasis: considerations for ICD-11 Odile A. van den Heuvel,1,2 David Veale,3,4 Dan J. Stein5 1Department of Psychiatry, VU University Medical Center (VUmc), Amsterdam, The Netherlands. 2Department of Anatomy & Neurosciences, VUmc, Amsterdam, The Netherlands. 3Institute of Psychiatry, King’s College London, London, UK. 4Center for Anxiety Disorders and Trauma, South London and Maudsley NHS Foundation Trust, London, UK. 5Department of Psychiatry, University of Cape Town, Cape Town, South Africa. The World Health Organization (WHO) is currently revisiting the ICD. In the 10th version of the ICD, approved in 1990, hypochondriacal symptoms are described in the context of both the primary condition hypochondriacal disorder and as secondary symptoms within a range of other mental disorders. Expansion of the research base since 1990 makes a critical evaluation and revision of both the definition and classification of hypochondriacal disorder timely. This article addresses the considerations reviewed by members of the WHO ICD-11 Working Group on the Classification of Obsessive-Compulsive and Related Disorders in their proposal for the description and classification of hypochondriasis. The proposed revision emphasizes the phenomenological overlap with both anxiety disorders (e.g., fear, hypervigilance to bodily symptoms, and avoidance) and obsessive-compulsive and related disorders (e.g., preoccupation and repetitive behaviors) and the distinction from the somatoform disorders (presence of somatic symptom is not a critical characteristic). This revision aims to improve clinical utility by enabling better recognition and treatment of patients with hypochondriasis within the broad range of global health care settings. Keywords: Hypochondriasis; illness anxiety disorder; obsessive-compulsive and related disorders; definition; classification Introduction caused by medical conditions and that warrant medical evaluation and/or treatment. Certainly, from an evolu- The World Health Organization (WHO) is currently tionary perspective, an appropriate level of anxiety and revising the ICD. The 10th version of the ICD1 was response to somatic alarm symptoms may have adaptive approved in 1990, almost 25 years ago. The development value. However, when concern about health becomes a of ICD-11 requires attention to the relevant historical matter of preoccupation and continuous fear or distress, it background as well as to more recent developments interferes with daily life. in understanding of clinical entities related to illness Individuals with such concerns may meet the diagnos- preoccupation and fear. This article addresses the tic requirements of the DSM-IV-TR5 and ICD-101 diag- question of how hypochondriasis should be described noses of hypochondriasis and hypochondriacal disorder, and classified in the ICD-11, and addresses the con- respectively. Hypochondriasis has negative effects on siderations reviewed by the members of the WHO ICD-11 quality of life, social and occupational functioning, and Working Group on the Classification of Obsessive- health care resource utilization, and is thus an important Compulsive and Related Disorders in their proposal for mental disorder to recognize and treat in clinical practice. the description and classification of this disorder. Although health care practitioners are familiar with those Preoccupation with bodily symptoms and fear of patients who seek reassurance during repeated visits to suffering from a serious disease falls on a continuum health care services, resulting in high health care costs, ranging from a very mild concern about some unusual unnecessary diagnostic interventions, and disturbed bodily sensation or observation to severe preoccupation patient-doctor relationships, hypochondriasis can also and fear or conviction in individuals in whom thoughts and lead to severe avoidance, risking unfavorable delays in actions are centered around the overestimated risk of case of actual diseases. In most patients with hypochon- 2 having or developing a serious, life-threatening illness. driasis, symptoms wax and wane, with acute exacerba- Taxometric studies have empirically confirmed that tions triggered by stressful periods – e.g., due to loss of a anxiety about health is a dimensional rather than a family member, a past experience of actual organic 3,4 categorical construct. Normal expressions of concern disease, and social circumstances, or in response to about health and alertness towards bodily symptoms may hospital and disease-related items in the mass media.6 be a useful response to changes in the body that are Correspondence: Odile A. van den Heuvel, Department of Historical background Psychiatry, VU University Medical Center, PO Box 7057, 1007 MB, Amsterdam, The Netherlands. Hypochondriasis as a psychiatric concept has been the E-mail: [email protected] subject of considerable controversy over the centuries. S22 van den Heuvel et al. Today, hypochondriasis is considered a mental disorder, of self-directed exposure and cognitive change (cognitive but in the 17th century it referred to a common somatic reappraisal) are successful in the reduction of discomfort condition, with the name hypochondria, introduced by and attenuation of the urge to seek reassurance. Hippocrates and literally meaning ‘‘below the cartilage,’’ The long-lasting debate on both the terminology and suggesting the involvement of abdominal organs. The the conceptualization of hypochondriasis is currently transformation of the description over time, with the initial focused on the following issues12: 1) is hypochondriasis reference to a mental condition occurring in the early 19th a distinct primary medical entity or a secondary feature of century, has been described extensively by Noyes.7 other psychopathologies? 2) what are the discriminating Briefly, 17th century authors, still strongly influenced by diagnostic features of hypochondriasis and how can Galen’s views of pathogenesis, related hypochondriasis these be differentiated from normality? and 3) how best to to melancholic personality traits, caused by somatic classify hypochondriasis, taking into account its relation digestive disturbances. Psychological concepts became to somatoform disorders, anxiety disorders, and obses- more prominent in the description of hypochondriasis sive-compulsive and related disorders (OCRD)? Here, we from the late 18th century onward. At that time, it was summarize the existing but limited literature on these thought that a depressive ‘‘morbid’’ state would change issues, as well as recent developments in relation to body awareness, resulting in digestive disturbances. DSM-5, and propose the options for ICD-11. Although attention started to switch from the intestines to the brain in the 19th century, hypochondriasis became The ICD-10 approach to hypochondriasis regarded as a neurosis, i.e., a functional rather than structural disturbance. Fear of serious illness was In the ICD-10 Clinical Descriptions and Diagnostic emphasized as its principal characteristic, digestive Guidelines for mental and behavioral disorders,13 hypo- symptoms were no longer considered as crucial, and chondriacal symptoms are described in the context bodily preoccupation and hypervigilance and abnormal of both the primary condition hypochondriasis and illness behaviors started to receive attention. During as secondary symptoms of a range of other mental this ‘‘physical-to-mental’’ transformation of the concept entities (e.g., delusional disorder and depression). of hypochondriasis, it became one of many mental Hypochondriacal disorder (F45.2) is included in the disorders. The historical review by Noyes, mainly focus- grouping of somatoform disorders. Its main character- ing on the 17th, 18th, and 19th centuries, shows the istics are: 1) the persistent belief in the presence of at influential role of social and cultural factors in shaping the least one serious physical illness underlying the present- description of the disorder over time, and the uncertainty ing symptom(s), even though repeated investigations and about how to classify the disorder in relation to other examinations have identified no adequate physical clinical entities. explanation, or a persistent preoccupation with a pre- Psychodynamic theories of hypochondriasis mainly sumed deformity or disfigurement; and 2) the persistent focused on the role of (unconscious) guilt over sexual refusal to accept the advice and reassurance of several and hostile wishes, fantasies, and feelings that must be different doctors that there is no physical illness or disguised to avoid overwhelming fear of punishment, abnormality underlying the symptoms. Five partially 8 bodily damage (castration), and death. The psychody- overlapping inclusion terms are listed for hypochondriacal namic term hypochondriacal neurosis was adopted by disorder, i.e., body dysmorphic disorder, dysmorphopho- DSM-II, and despite criticism of and controversy about bia, hypochondriacal neurosis, hypochondriasis, and both the relevant terminology and construct, the terms nosophobia, indicating that any of these phenomena hypochondriasis and hypochondriacal disorder persisted should be assigned the diagnosis of hypochondriacal 9 in subsequent revisions of DSM and ICD. disorder. Current concepts of hypochondriasis have been Based on more recent research,2 some aspects related considerably